i'm an adapter!

Sunday, July 10

In the business of child health, a mentor once taught us that we must always be ahead of the babies and children. From the moment they come in, we should already be able to anticipate the course of the illness, complication and recovery, and pre-emptively sort them out. We do not wait until the problem arises, then go into a panic mode and make rushed decisions.

In the district hospital that I used to work in, this ethos is well understood by the whole team. From the outset, if the doctor or nurse who first saw the child have any concern, whether it is a diagnostic dilemma or that the child did not look so good, we would talk to each other about it. We may alert the parents and the rest of the team about the concern or put on extra monitoring in a place easily noticed, and make sure that a senior personnel is to see the child before nightfall. When I first started in Paediatrics, I was an anxious ball and would become agitated over every tiny anomaly which I did not expect to find. But I am grateful that even as a junior member of the team, my concerns were usually taken seriously. Hence we are able to prevent lots of unanticipated problems.

This is very different in the adult wards, especially the medical wards. It is extremely common to have several deaths in a day, more than half of those were unexpected, resulting in several 'crash calls' in a day (or night). 'Crash call' is a panic button that summons a team of doctors and nurses to come immediately, and is to be pushed only when a patient deteriorates critically suddenly. 'Crash call' in the UK hospitals are quite well run because the members of the team have been exposed to different scenarios simulated beforehand in training. But, over here, it is more like a circus of confused people arriving, no leader, no effective communication, only grumble and criticism at this most inappropriate timing. Needless to say, the patient outcome is usually poor.

One of my colleague who used to work in the adult medical department, had recently join Paediatrics, and was asked to present on a case of a child who deteriorated during the early hours in the morning during his oncall duty.

'The child was admitted at 3pm, with a chief complain of fever, altered behaviour for 3 days and 1 episode of seizure which lasted for 20 minutes'. On arrival his GCS was 11 out of 15 but haemodynamically stable. He was reviewed by the specialist at 5pm and started on antibiotic and anticonvulsive treatment. Night review was done at 7pm and the child's condition was the same. At 4am the staff nurse was called by the mum as the child had suddenly became unresponsive. On my review, the GCS was 3 out of 15, hypotensive and bradycardic. He was intubated and sent to ICU.'

The boss was clearly unhappy.

'In medicine, there is no such thing as 'suddenly collapsed', 'suddenly deteriorated', 'suddenly became unresponsive'. I do not want to ever hear those words again. The child was last seen at 7pm, What happened between 7pm and 4am? The child was at the acute bed with continuous monitoring. What did the observation show? What was the level of consciousness in the interim?'

My colleague were unable to answer. GCS was not recorded and observations were not documented clearly during the interval 9 hours. For the child to deteriorate to the point at 4am, there would have been some signs that the body was compensating, and all the members of staff on duty that night have failed to pick them up. From this example, we all got the message and went on to improve patient care by working on this very basic principle of medicine for every single child that came through the doors.

I requested for transfer to this tertiary referral centre to further my training in Paediatrics. To my dismay, such basics are even more poorly done here. There is a systemic problem of too many staff, too many teams, too many leaders, too many egoistic heads, as well as a system of office politics and culture that have been ingrained in this institute for many decades that are not easily corrected. The Paediatrics department is huge and the sub-departments who are supposed to provide support are not always easy to talk to. I see more of the bad habits of adult medicine surfacing, for example kicking patients like a ball from one sub-specialty to another, or from one ward to another, to avoid the responsibility of being the primary team. Every workplace has its strengths and weaknesses, and it is working with the systemic limitation that upsets me because I cannot give the best to my patients.

However, as another of my mentor who has worked in this dinosaur institute for many years said: 'Aim to save one patient at a time'. I am a tiny minion and I have conceded that I cannot change the system. So I am using the principles of good practice that I have learnt to look after the few patients I see. And so far, I have been able to prevent a few patients from failling into the state of 'suddenly collapse' by starting antibiotics early, fluid resuscitating early, starting inotropes early, referring to ICU early.

One of the parents once told me he would like his son to be admitted to ICU because he felt the doctors there are better. In his son's previous hospital stay, he had experienced watching the ICU doctors rushing to the ward in an emergency, intubating the child, performing chest compressions, inserting various lines to save the child. He felt that the ward doctors were inferior as these jobs are not their routine. This is the trouble with people watching too many dramas on TV, who sensationalises this heroic image of being a doctor.

Please. Every doctor is able to help in any emergency situation, but to what extent? If only one can feel what a doctor feels during those surprise 'patient collapsed' situation: rushing to the scene, internally your heart is palpitating away, you feel a little dizzy from hyperventilating, your hands become cold and your brain starts to freeze; externally it is a havoc, no one knows what is going on, who is who in the team, who is this patient, where equipments are kept and who has done what. Besides, once a patient succumbs to the point needing CPR, much irreversible damage has been done. The patient stands little chance being treated in this extremely uncontrolled environment. It improves though, the profession has started to realise the importance of teamwork and effective communication in such high stake scenarios (but this awareness has yet arrive here, I am afraid).

Who you really want is a doctor who is able to prevent you from falling into that state. Problems are always easier to tackle when recognised earlier. There is completely no need for 5 doctors rushing to stick huge needles all over the patient instituting invasive treatment when one injection of antibiotic given 5 hours ago could have prevented all these.

An unknown hero is the real hero. But a good doctors do not care, he or she just want to be able to sleep well at night.

Saturday, April 9

One of the most amazing insights that I have gained working with child is seeing how this group of little creatures adapt to misfortune.

Parents are often upset when they learn of a disability in their child. A child born without his right arm, a girl with a spinal deformity making her never being able to walk, one who has hereditary cancer of the eyes that defines her blind. Even the doctors and the nurses cannot help feeling pitiful for the kid. How is this child going to survive life, in this cruel, unforgiving world? We foresee the mountains of difficulties. The child would be looked at and treated differently. Kesian, kesian... This must have been the expression most commonly surround this child from the time he arrive in this world.

Fortunately, the child being born ignorant does not comprehend such expression. He does not realise that how others see him matter. He does not understand that it is a deficit to be born without a limb, or a sense. He simply go about exploring the world with whatever resource he has with him, and make a sense of this world. And he would find journey of exploration as enjoyable as his counterpart born 'perfect'.

S was my first teacher. He is now 18 years old. The senior paediatric orthopaedic surgeon of the team had known him since he was born and keeps a photo record of his case from the time he was a neonate till now. He showed us pictures of his legs auto-amputated from the knees while he was still in the mother's womb. As a result, his leg prosthesis have been part and parcel of his life since. Yet, there is nothing to feel sorry about for him. He is as lively as any other boys, who would sometimes test the patience of the the adults, just to see where is the line drawn. When I was attached to the team, this boy was admitted for infected wounds on his knees. He has been told to get off his prosthesis for a few months in order for the wounds to heal, but how would he go about doing Taekwondo (a black belt holder), going out with his girlfriends and training with his police cadet corp in school without his prosthesis? So the wound deepened and he was admitted. In the ward, we were able to take away his prosthesis to rest him forcefully. That was the plan, but it didn't work. Often I cannot find him on his bed, or even in his ward. He would often be on the wheelchair, roaming the corridors and in the other wards trying to chat up the other patients making friends. I once caught him in the men's toilet, holding on to the plastic bars frame of the toilet doors doing pull ups! When I met his mother once, out of routine, I asked her if S has been registered an OKU (as a disabled person). To my surprise, the answer was no, eventhough there is no doubt that a double amputee qualifies for the label. It is not because of the fear of stigma or anything complicated like that. The mum genuinely did not feel that S is an OKU, being him as he is doing normal this that boys of his age do.

This boy made me believe that there is no need to feel pitiful for children with disability, in contrary to what I have been taught. Remember those moral lessons in school, that compelled the students to have a 'sikap belas kasihan' to blind people? I am a sure a professional film crew can easily cook up a sob story about S along with all the melancholic sound effect to accompany the story of this unfortunate boy who was born without his legs. We have all seen it. But the reality is not like this. The difficulties they face in adulthood arises from such societal conditioning that we are subjected to. If we all treat S like how his mother treat him, i.e. a normal person who will try and manage with whatever resources that is available to him, there would not be any difference between us and them.

Later on in my career, I have had to meet parents of children born with problems. A child without a limb, a blind and mute baby as a result of a congenital infection, a child with very limited sight due to his extreme premature birth, a boy with speech delay who portrays features of autism, a child would cannot read and most likely has dyslexia, a child with cleft lip and palate etc. Parents to newborn with such problems are often very worried and upset, but I am always able to confidently convince them that it is a manageable situation, that it is not the end of the world. As the child grow up into toddlerhood, it is very satisfying to see parents bringing in their child to clinic in a relaxed state, sometimes chasing after their child telling them off for being naughty, in other word treating them like any other children. These special children know their children so well and takes pride in any strength their children display, and I am always delighted to learn about this side of them.

Cognitive disability is sometimes less easy to adapt compared to physical disability, just because of our education system which caters too narrowly for the most academically able group. I dare say of all the 'normal' children, at least half are not be able to fully benefit from our education system, in the sense that the system does not bring out the best potential of each child. I have often received referral from schools who want their student to be signed off as an OKU (with cognitive problem or learning disability) because they cannot keep up in the mainstream school. In the form, the doctor is suppose to recommend appropriate education placement for the child. I am often perplexed that I should be filling up this component. I am reluctant to label any child OKU just because they are non-specifically slower in learning compared to their peers, bearing in mind that I am not particularly a bright student myself. The teachers and psychologists are supposed to be the ones who are the expert in this field, not a doctor. I cannot simply choose and tick a box putting a label to a child after one clinic session. I often spend these sessions discussing with parents the actual aspects that is problematic about the child (in contrast to what the school thinks), the aim of education specifically for this child, how to ensure he can lead an independent adulthood. I teach them to rely less on the system and put more effort to help themselves.

A disability in a child is not a curse. It does not bother a child and it should not bother us. Every individual is unique in their own way and we should allow each to develop into their full potential in their own way. I thank all the special children and their family whom I have the privilege to work with in all these years, dispelling the dogma drilled into me, and teaching me a unique kind of resilience I did not know exist.

Sunday, July 6

This blog
has been abandoned for a while. It is not that I don’t want to write anymore. I
know a few of my colleagues have stumbled upon this blog and I don’t want to
make my private thought public especially at my work place. But, I am now at
the point of ‘TAK TAHAN LAGI’ and desperately need an avenue to vent.

I have been
working here in this district hospital for a year and a half now. In
the first few months, it was immensely enjoyable. The learning curve was very
steep. I would come to work early and leave late to help around, get that extra
bit of practice or to see the interesting patients. My colleagues would make
silly joke all the time and made me laugh everyday to the point my cheek and
belly hurt from exhaustion. The experience was so good that I declined an offer
for a paediatric medical officer post from my old teaching hospital.

Now, it is
just the opposite. I feel unmotivated. I feel work is routine. Every morning
when I wake up, I contemplate faking an illness to be absent from work.

My upbringing, education and training made me expect a high standard
of myself. It is not good enough to do just enough, it has to be better than
that. Similarly, I expect my teachers to be better than me. I am trained to
always keep an open mind, always ask why, always to look at an issue from different
perspectives.

The problem
with training in this hospital now is that the specialists in charge of the
wards are new specialists, fresh from passing the exams, having been medical
officers just like me a few months ago, sent here for a stint of gazettement.
Hence I do not find their rounds as worthy for my training as compared to, say,
a ward round with my previous consultant who was near retirement age. I do feel
arrogant writing this, and I have tried to think of it another way. But there
is no other way of putting it. This is how I truly feel.

The feeling
is exactly the same like when I was a house officer having to do round with a junior
medical officer, who did not having the experience to make any meaningful decision,
whose basic knowledge was shaky at best and not only was unable to teach my anything
useful, I found myself having to fill in gaps in their inadequacy. With this
type of medical officers, I found that registrars and specialists often like to
hear from me or convey their management plans to me directly, without going
through the medical officer. That made life a lot easier for me without having
to go through an intermediary.

In
Malaysia, this is considered close to unacceptable. Respect for the people
older than us, people who are considered our senior, people who are more
experienced, had been drilled into every Malaysian kids by the time they finish
school. My mere thought of the kind mentioned above would have me labeled as
someone disrespectful. Biadap, they call it in Malay.

Of course,
most housemen in Malaysia are not like me. Most are obedient and do not judge
their medical officers like me. Most just follow order, get the job done, and
that’s good enough. And that work routine carries on when one becomes a medical
officer, who follows orders, who doesn’t judge their specialists.

Once
mastering the basics after a few months at work, I began to think about
our current medical practice, to read up more broadly. And I became more
unsettled with a few things on the way we work. I started to ask questions. It
wasn’t received well. They were often met with silence when I discussed them
with my colleagues, and when brought up to the boss, occasionally ended with
heated argument.

It
frustrates me very much when I am forced to practice medicine in such old
fashion way. When I asked why, I get vague answers. I am not stuck up. If there
is a plausible explanation, I can accept it. The logic around here probably makes
as much sense as the logic of witchcraft. I don’t know. Maybe I have not enough
grey matter to understand. Maybe there are extenuating circumstances why we
cannot follow the standard practice and in accordance to the best available
evidence.

I am critical of the way we manage things here. I feel things could
have been better. But no one else would speak up. Sometimes I feel I am leading
a rebellion, trying to convince my colleague of a different point of view from
what the bosses think. And they do not take it well. They all asked me to tone
down, not speak up. ‘Just follow, no need to think.’ I was told, and
my soul would be at peace. She was too kind in her words. Another had harsher
words: ‘She thinks she is smarter than the specialist.’

Paediatrics appealed to me because I feel
paediatricians are proper clinicians. During housemanship time, I was most
unimpressed with doctors from adult specialties, whom after only a quick
cursory interview and examination, often order a battery of tests and imaging
without much consideration or justification. In contrast, I liked what I saw in
paeds. Answers were often found in a thorough history and examination. In
teaching rounds, professors often encourage us to make accurate, confident
diagnosis, to fine tune management. Yes, the child has been having fever for 3
days, but if it is a viral fever, there is no need for antibiotic. In those
days, there cannot be such a thing as ‘antibiotic just to cover’. They pay attention to teach us clinical judgments – how to differentiate a viral vs
bacterial pneumonia and the likes. And they pay attention to explanation and
education to the parents. I believe this is how medicine should be practiced.

But it is not the case here in this district
hospital. Not to say that histories and examinations were bad, but I just do
not understand why it is so different. I cannot count how many children we
‘empirically treat as pulmonary TB’ without much as a shadow of lymph node on chest
x-ray. There has been even more children, maybe in the thousands, subjected to
antibiotics they do not need for viral illnesses. There has been too many
unnecessary lumbar punctures evidence by the overwhelming negative results (I
have never seen a culture positive CSF). Sometimes even myself as a junior medical
officer, am able to tell with confidence that a fever is viral in nature, hence
do not need antibiotic, only to have my decision overruled by the specialist
later, adding antibiotic with the reason ‘just to cover’. Our head of
department wants us to be safe, by over-treating rather than be perfect. I
disagree. Every x-ray is radiation, every ultrasound takes up time (and every
negative ultrasound makes the radiologist think less of us in paeds), every
drop of blood is precious in a little human, and every poke is a trauma to the
little one’s childhood. Overuse of antibiotic breeds resistant organisms.
Over-investigation and overtreatment increase anxiety in the parents. If we are
going to overtreat everyone, what is the use of learning clinical medicine? We
only need to take a single sentence presenting complain, take a look make sure
nothing obviously wrong, then proceed to all investigations, wack some antibiotic 'to cover', like how they do
it for the poor adults. I am not learning much clinical acumen here as you
probably can tell. Hence, I feel my time is up here in this district hospital.
This is a shame. The myriads of disease presentation here is amazing and I
could have seen the best of medicine here.

During university days, I used to run workshop
convincing other students to join my cause for the right of refugees, fighting
the policy makers, with a motto of never taking no for an answer. Here, nobody feels
righteousness is something worth fighting for. In this lonely battle, I have
lost confidence and motivation. I am tempted to give in, to quit thinking, to
be comfortable and just follow like a robot.

Tuesday, February 11

I suppose it happens. I ask too much too often. But it isn't fair that I blame everything on myself. It is all about work. After all, for the past year, other than the 20 days or so of annual leave I took, I spent at work. That is more than 340 days at work in a year. We are required to work everyday including weekends and public holiday. It does take a toll and wears one off. Ward round is mundane, even for the patients and parents on short stay, and there are plenty of those in a working day. There are problems to be solved everyday and certain amount of distasteful jobs to do every few days. There is no scope for life outside work here at this place.

I try to do my best at work though, I really do. It is not please the boss, not at all. I am privileged to be able to be in such position to help, to make a difference. The fortune teller said it is because in my past life, I had saved a drowning man. I am not particularly superstitious or religious, but I believe in karma and morality. Whatever good or bad things I do will eventually come back to myself or my family. But due to my inexperience and ignorance, sometimes, no, often, even doing my best is worthless. I make mistakes sometimes, including few medication errors, and that had been quite upsetting. Quite often I do become frustrated if I know things could have been done better for my patients, because of the action and decisions made by myself or others. But I have never and would never cry for my patient. There has to be professional distance. But I feel I ought to set even wider distance, never to allow patient issues affect me at all. Yet I do not see how that is possible - my life is work, and only work at the moment. Erasing feeling aroused from work equals no feeling, or so my logic says. Unlike in the west, the medical profession do not reflect much, we do not discuss feelings. That is just the working culture here.

I do long for an acquaintance. Not necessarily a male counterpart. Just someone I can relate to and talk and vent for hours, a nice company to have dinner with. I spend most of my time outside work (for necessities like groceries shopping and dining) on my own. I am not embarrassed by that. But it does get a little lonely. Colleagues are nice enough, but I am not getting along well with a few. My wavelength and theirs are simple different.

You can say in some perspective that I am depressed. I cannot see the future. All very dark. I cannot see myself passing the next paper. I cannot see myself taking the next step getting out of this place.

Saturday, December 21

There were many pieces I have written in the past that have been left unpublished for the blog, for many reasons: unfinished, considered inappropriate for public reading, too frustrated to continue etc. Two of which made me laugh when I look back.

'The more you put in, the more you get out of it. You don't even
have to know a lot, you just have to be keen!' One of the consultant said this
to me one day. I reflected upon it. Did I not seem very keen? Did I give him
the impression that I was bored?

This is the most difficult thing about studying medicine. It isn't
the vast medical knowledge that we are expected to learn. It isn't even the
extraordinary hard work that we have to put in. It is having to appear
enthusiastic, keen, energetic all the time.

You'd realise the fact on the very first day you set foot into the
hospital in the third year. Hospitals are very busy and unfriendly places.
Doctors and nurses have 1001 things to do already and routine is very important
to be efficient, so more can be done in a shorter span of time. Doctors and
nurses tend to cope with the madness of hospital chaos by sharing a
strange a camaraderie. Because we don't work within the circle, medical students are not included
in.

I suppose I am awkward compared to my fellow friends because I
like to work. I love being in hospital, I like helping doctors and nurses, I
intrigued that I learn new things everyday. I hate laziness and I cannot stand
being idle.

In my third year, on our very first placement, one of the consultant tried to get me doing jobs
as part of the medical team, and that was such a rare thing.

However, even for me, I feel that sometimes I just have not any
energy left to pull up that keen face that we are suppose to show all the
time.

This was written when I was nearing the end of my fifth year. I suppose the exhaustion had started to kick in, exhaustion of being a student. I was the model student. I wanted to make good impression of every senior person I met, and that took quite a bit of effort.

1. Staff nurse - don't be angry if i don't entertain your request
stat. because I have more urgent things to do first.

3. Relatives - talking to mi-si is so much
better than talking to me - they know useful things like where is the parking, etc. i'm only a houseplant.

4.

This was written two months into my housemanship training, at the time working in excess of 100 hours a week, mainly due to my inexperience of prioritising tasks and trying to please all the mi-si and patients who also called me mi-si. I used to think they call me mi-si because I did not appear confident (and I was probably right), hence the use of 'I' in small letters 'i'. Clearly I had more to say in this piece but now I cannot remember who else I have had resentment towards..

Tuesday, January 1

It is now coming into my third week working in a district general hospital in Sarawak. I always have thought of working in East Malaysia embracing a whole new experience, perhaps not yet having the guts to accept a job at remote places only accessible by boats and helicopters, but being actually here now on this side of the world is a good start.

Moving was daunting - all the fuss with finding a house and car. Luckily I had help from a friend's parents, without whom I'd be so stuck.

I am lucky enough to be accepted into Paeds. The first week was tough. Besides having to get used to the new system in general, I quickly realised that despite having done paeds just half a year ago and having recently passed an exam, my knowledge is minimal and sort of have to start from zero. I like the bosses here because they are strict and have high expectations. It is a steep learning curve but I am enjoying paeds more and more everyday. I like micromanaging baby's nutrition, manipulating baby's ventilation, working together with parents. Nurses are so capable here than the ones I've worked with before. I couldn't ask for better colleagues than this bunch who had been kind enough to include me in every meal and every outing they've planned. It's been interesting interacting with Sarawak people, whose accent I absolutely adore.

Thursday, November 29

Some update. I passed MRCPCH Part 1a and 1b. With good scores if I may add. I did work hard to prepare for this exam and I am so glad that my effort had paid off. I am proud of this achievement.I am now 'floating' in the Orthopaedic department. I was actually unclear of my role. I am in the HO roster, assigned as the Paeds Ortho team's HO, as I have promised to help out since we are short of HOs at the moment. The difference is that nowadays I consult my seniors less and tend to just go ahead with what I think is appropriate in terms of clinical management. But I do not sign MC as I have not obtained my full MMC registration number, and I avoid signing on operation consent forms. Last Friday, we were chatting and I accidentally let slip to prof, who is also our head of department, that I am actually neither doing shift work nor oncall. On Monday morning, prof delivered the news that I will be assigned to do the MO calls. It was a mixed feeling. I am happy that I am upgraded to do MO's work and would be able to earn some extra cash. On the other hand, my luxurious ways of working office hours would be sorely missed. On the next day, we had a visiting professor from Indonesia joining our round. Prof introduced our team to the visitor and a sense of pride overwhelmed me when prof introduced me as 'one of our new MOs in our team'. I actually smirked uncontrollably. So embarrassing Now I feel I have to really up knowledge and improve to live up the standard of being an MO. As opposed to my expectation, I really enjoy being in my team now. The main reason is the bosses. The two professors heading my team are great old school doctors who give much emphasis on how a patient is clinically to determine diagnosis and treatment, as opposed to fancy tests and scans. A 7 month old boy came in with high fever, not moving the left hip, all the signs pointing at septic arthritis but because the ultrasound concluded that there isn't one, the MOs did not treat for the condition. Prof listened to the story, took one look at the child and sent the boy straight to OT. Impressive enough, needle into the hip, pus poured out. It was septic arthritis. Unlike the MOs, prof trusted the clinical presentation rather than technology, and he made the correct diagnosis. I could have gave him a salute. There were other examples. In general, there is less unnecessary referral and requests for scans in Paeds Ortho team compared to the other Ortho teams because our profs are more sensible. I like learning proper medicine from these sensible old school doctors. It also reinforces my believe that Paediatric doctors (physician or surgeon) are simple cleverer and more conscientious doctors. Even though I am the most junior in the team, I have never felt the hierarchy preventing me to ask questions and express my point of view. In fact, prof would always ask what I thought I would do before he suggests his management.

However, ortho is ortho and I cannot deny losing interest when conversation starts to veer towards operative technique, anatomy... I am in the process of trying to continue floating in the real Paediatric department, where my real interest lies. We will see how this pans out. Should be interesting. There is a previously-known-to-be-stubborn kiddo in the ward now. Prior to this, we needed to change his dressing under GA or sedation every time as he would scream through the roof when anyone touched his foot. But, as of yesterday, I have managed to tackle him and we are good friends now. With me he was so cooperative that he held his hand out still for me to poke him to take blood, not making a sound and concentrated on his breathing just like I told him to. So cute. After that he even gave me a pack of his sweets. Today was not the greatest day. I messed up a case in my presentation. Prof wasn't happy and I felt disappointed with myself. But after that, I went back to the ward and played with this kiddo. He cheered me up and made my day..